Diastolic Dysfunction w/o CHF RE: 6485343

ssalinas

Diastolic/systolic dysfunction by itself codes to heart disease. It has
to be associated with CHf or stated as dias or sys heart failure to get
to the 428.xx





Diastolic or systolic dysfunction without heart failure

Coding Clinic, First Quarter 2009 Page: 7 Effective with
discharges: March 27, 2009



Question:



Is a diagnosis of systolic or diastolic dysfunction coded the same as
heart failure?



Answer:



No, diastolic dysfunction without mention of heart failure is indexed to
429.9, Heart disease, unspecified. It is not appropriate to assume a
patient is in heart failure when only "diastolic dysfunction" or
"systolic dysfunction" is documented.









From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Tuesday, March 01, 2011 8:39 AM
To: Salinas, Sharon
Subject: RE: [cdi_talk] 6485343



THANK YOU SO MUCH!!!







From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Tuesday, March 01, 2011 10:35 AM

Subject: RE: [cdi_talk] 6485343



Here you go. This is one of latest.



Systolic dysfunction with congestive heart failure

Coding Clinic, First Quarter 2009 Page: 8 Effective with
discharges: March 27, 2009



Question:



The patient is documented as having systolic dysfunction with acute
exacerbation of congestive heart failure (CHF). Can this be coded as
acute systolic heart failure with congestive heart failure?



Answer:



Assign code 428.0, Congestive heart failure, unspecified and code
428.23, Systolic heart failure, Acute on chronic. Acute exacerbation of
a chronic condition (heart failure) is coded as acute on chronic.



ICD-9-CM's Alphabetic Index provides the following direction for
systolic dysfunction with heart failure:



Dysfunction

systolic 429.9

with heart failure -- see

Failure, heart



Additionally, congestive heart failure is not an inherent component of
systolic or diastolic heart failure. When the diagnostic statement lists
congestive heart failure along with either systolic or diastolic heart
failure, two codes are required to report the specific type of heart
failure: congestive, diastolic, and/or systolic. This advice is
consistent with that published in Coding Clinic, Fourth Quarter 2002,
pages 52-53 and Fourth Quarter 2004, page 140.





Sharon Salinas, CCS

Extension 3336



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dbutler

My understanding of the phrasing that includes the operative word "with" does not require an explicit link by the documenting physician to be able to code the more specific HF ICD9 code; in other words, if the medical record contains both the identification of diastolic dysfunction and of CHF, one should be able to code the specific even without the physician directly associating the 2 diagnosis.

This is differentiated from a case that does not have CHF/HF documented and only has diastolic dysfunction documented. This is the scenerio I believe this coding clinic is addressing.

Thoughts?

Don

ssalinas

Agree - They do not have to be linked. Documentation of both conditions
just have to present in the record. I stated it poorly in the earlier
email. Thanks for clarifying!

Sharon Salinas, CCS
Extension 3336

catladyrn

Don, that's how I've always seen it, and how the coders have taken it. As long as they're both documented, they can be linked. One of the few situations where this is so.

Renee


Linda Renee Brown, RN, CCRN, CCDS
Certified Clinical Documentation Specialist
Banner Good Samaritan Medical Center